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รศ.นพ.พ�ศาลไม้�เร ยง รศ.นพ.กิ�ตต� จั�นทร�เสิ�ศฤทธิ์�� อ.นพ.เทพสิรรค์� สิ อร�าม้ร��งเร�อง

Disclosure of commercial support Disclosure of commercial support

This lecture is support by Berlin

pharmaceutical industrial company.

The speakers are free to present their

own information and their personal

view without any influence from the

company.

สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไปรพ.ศร นค์ร�นทร�จั'านวนค์ร�(งและร�อยละของผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 25.

ล'าดั�บ

รหั�สิโรค์

ช�!อโรค์ จั'านวนค์ร�(ง

ร�อยละ

1. I10 Essential (primary) hypertension 11,905 2.32

2. K30 Dyspepsia 9,594 1.87

3. E11 Non-insulin-dependent diabetes mellitus 8,944 1.74

4. E05 Thyrotoxicosis (Hyperthyroidism) 8,399 1.63

5. J45 Asthma 7,342 1.43

6. I05 Rheumatic mitral valve disease 6,346 1.24

7. J30 Vasomotor and allergic rhinitis 5,912 1.15

8. J06 Acute upper respiratory infections of multiple or unspecified sites

5,406 1.05

9. C22 Malignant neoplasm of liver and intrahepatic bile duct

5,377 1.05

10. H90 Conductive and sensorineural hearing loss 5,305 1.03

สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไปรพ.ศร นค์ร�นทร�จั'านวนค์นและร�อยละของผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 2547

ล'าดั�บ รหั�สิโรค์ ช�!อโรค์ จั'านวนค์ร�(ง ร�อย ละ

1. K30 Dyspepsia 3,634

2. T14 Injury of unspecified body region 2,771

3. I10 Essential (primary) hypertension 2,580

4. J06 Acute upper respiratory infections of multiple or unspecified sites

5. E05 Thyrotoxicosis (Hyperthyroidism) 2,292

6. J45 Asthma 2,083

7. J02 Acute pharyngitis 1,957

8. J30 Vasomotor and allergic rhinitis 1,702

9. A09 Diarrhoea and gastroenteritis of presumed infectious origin

10. M62 Other disorders of muscle 1,686

สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไป รพ. ศ-นย�ขอนแกิ�นสิถิ�ต�ผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 2546.

ล'าดั�บ

ช�!อโรค์ รวม้ รวม้ท�(งหัม้ดั

ชาย หัญิ�ง รวม้ ร�อยละ1. I10 Essential (primary) hypertension 6,011 10,413 16,424 2.85

2. E119 Non-insulin dependent diabetes mellitus

4,870 10,290 15,160 2.63

3. J069 Acute upper respiratory infection 3,714 4,711 8,425 1.46

4. N200 Calculus of kidney 4,770 3,082 7,852 1.36

5. K30 Dyspepsia 2,525 3,859 6,384 1.11

6. H251 Senile nuclear cataract 2,036 3,010 5,046 0.88

7. K021 Caries of dentine 1,408 2,707 4,115 0.71

8. A09 Diarrhoea 1,798 2,283 4,081 0.71

9. J00 Acute nasopharyngitis (common cold)

1,833 2,186 4,019 0.70

10. S099 Unspecified injury of head 2,763 872 3,635 0.63

สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไป รพ. ศ-นย�ขอนแกิ�นสิถิ�ต�ผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 2547

ล'าดั�บ

4,961 11,039 16,000 2.77

6. K30 Dyspepsia 2,562 3,993 6,555 1.13

7. A09 Diarrhoea 2,520 3,185 5,705 0.99

1,995 2,078 4,073 0.70

9. B24 Unspecified human immunodeficiency virus (HIV) disease

1,915 1,612 3,527 0.61

10. H110 Pterygium 889 2,142 3,031 0.52

สิถิ�ต�โรค์ท !พบบ�อยท !เวชปฏิ�บ�ต�ท�!วไป รพ. ศ-นย�ขอนแกิ�นสิถิ�ต�ผู้-�ป.วยนอกิ จั'าแนกิตาม้ ICD10 10 อ�นดั�บแรกิ ป0 พศ 2548. (ค์ร3!งป0งบประม้าณ)

ล'าดั�บ

3,338 6,967 10,305 3.22

3. K30 Dyspepsia 1,720 2,634 4,354 1.36

7. K021 Caries extending into dentine 1,033 1,886 2,919 0.91

8. A09 Diarrhea 1,156 1,170 2,626 0.82

1,226 1,285 2,511 0.78

10. B24 Unspecified human immunodeficiency virus (HIV) disease

1,240 1,007 2,247 0.70

Case 1Case 1

• ชายไทยค์-� อาย� 40 ป0 อาช พ พ�อค์�า• แสิบร�อน จั�กิเสิ ยดั แน�นท�อง 3

สิ�ปดัาหั�• ไม้�สิ�ม้พ�นธิ์�กิ�บอาหัาร บางค์ร�(งม้ ลม้

บร�เวณล�(นป0! ร�วม้ดั�วย• ไม้�ม้ น'(าหัน�กิลดั อ�จัจัาระป5สิสิาวะปกิต�

ไม้�ม้ ไข�• ไม้�กิ�นเหัล�า แต�กิ�นอาหัารบางค์ร�(งไม้�

ตรงเวลา•ไม้�กิ�นยาช�ดัแกิ�ปวดั

Case 1Case 1

• Thai man, not pale, no jaundice

• No lymphadenopathy

• Lung and Heart are normal

• Abdominal soft, no distension, liver

& spleen can’t be palpable

• No signs of chronic liver disease

•สิาเหัต�ท !ค์�ดัถิ3งในผู้-�ป.วยรายน ( ?

•Clue ในกิาร

diagnosis?

แสิบร�อน จั�กิเสิ ยดั แน�นท�อง

• What is/are causes?

• Clues for diagnosis

Normal physical examination

Causes of dyspepsia

Organ Pathogenesis Disease

Stomach and

Duodenum

• Acid

• NSAID

• Helicobacter pylori

• Tumor

• Infiltration

• Gastric ulcer

• Duodenal ulcer

• Gastritis

• Duodenitis

• CA stomach

• Eosinophilic

Causes of dyspepsia

Stomach and

Duodenum

• Acid sensitivity

• Gastric hypersensitivity

• Duodenal hypersensitivity

• Failure of fundic relaxation

to meal

• Vagal neuropathy

• Gastric dysrhythmias

• Delayed gastric emptying /

antral hypomotility

• H.pylori

• Small bowel dysmotility

Functional dyspepsia

Causes of dyspepsia

Liver and

biliary tract

• Infection

• Tumor

• Stone

• Hepatitis

• Liver abscess

• GS

• CBD stone

• Cholangiocarcinoma

• HCC

Causes of dyspepsia

Pancrease • Inflammation

• Tumor

• Pancreatitis

• Pancreatic duct stone

• CA pancrease

Diagnosis

A) Peptic ulcer - DU or GU

B) Gastroduodenitis

C) Functional dyspepsia

Functional 53.4%PUD

Hepatobiliary 16.9%

J Med Assoc Thai 1992;75:341- 8

N = 208

combined

Functional

65.6%PUD 11.3%

CA 1.8 %

Hge & Erosion 15.4%

Hepatobiliary2.6%

N = 221

Stomach Research group 1999

N = 531N = 208

NUD 76.6%

GERD 4.75%

PU 17.11%

CA 0.19%

รพ. ศร นค์ร�นทร� 2000-2002 J Med Asso Thai 1992

Functional 53.4%PUD

Hepatobiliary

combined

Clues on clinical evaluation

Disease Clues on clinical

1. Functional - Young patient, no alarm feature

2. Chronic peptic ulceration - NSAID used, HP-positive

serologically, smoker,

Hx of bleeding or anemia

3. Gastro-esophageal reflux - Heartburn or acid regurgitation

4. Gastric cancer - Advanced age at onset,

alarm feature such as weight loss,

HP- positive serologically

5. Biliary tract disease - Biliary type pain

Clues on clinical evaluation

Disease Clues on clinical

6. Chronic pancreatitis - Constant pain, radiates to back,

alcohol abuse, DM

7. Intestinal angina - Only postprandial pain,

afraid to eat, weight loss, smoker

8. Diabetes mellitus - Hx of DM, other DM complication

9. Drugs - Theophyllin, Iron, potassium,

digoxin, antibiotic

Dyspepsia

Uninvestigated Investigated

Organic disease Functional

Ulcer - like Dysmotility - like

Management of dyspepsia

Initial management strategies for

uninvestigated dyspepsia

1. Empirical treatment

2. Prompt endoscope

3. HP. Testing follow by eradication

treatment or endoscope

Empirical treatment

• Who should empirical treatment ?

• What is appropriate medication ?

Who should empirical treatment ?

• No alarm features

Alarm features

1. Age of onset > 40 years

2. Awakening pain

3. Significant weight loss (> 5% BW within one

month or > 10% within three months)

4. History of GI bleeding

5. Persistent vomiting

6. Dysphagia

7. Strong family history of GI malignancy

1999 Thailand Consensus SRG - GAT

8. Anemia

9. Jaundice

10. Hepatomegaly, splenomegaly,

lymphadenopathy

11. Fever

12. Abdominal mass

13. Significant abdominal distension

14. Bowel habit change

1999 Thailand Consensus SRG - GAT

Alarm features

1. New – onset dyspepsia over age 50 years old

2. Dyspepsia associated with dysphagia and / or weight loss

3. Evidence of GI bleeding

• Occult blood

• Anemia

• Hematemesis

• Hematochezia or melena

4. Using NSAID or ulcerogenic agent

5. Signs or Symptoms of UGI tract obstruction

• Early satiety

• Vomiting

6. Strong family history of GI malignancy

Prompt endoscopy : Alarm features or High – risk

American Society for Gastrointestinal Endoscopy

H.pylori Test-and-Treat Strategies

• Three direct comparative studies of early endoscopy and

H.pylori Test-and-Treat Strategies

Heaney A,1999

Lassen AT,2000

Duggan A,1998

measured dyspeptic symptom resolution

• Finding : H.pylori Test-and-Treat Strategies to be at least

as effective as prompt endoscopy in patients with no

alarm symptoms

Initial management strategies for

a) Empirical treatment

b) Prompt endoscope

c) HP. Testing follow by eradication

treatment or endoscope

A survey of etiology of dyspepsia and prevalence of H.pylori infection in every regions of Thailand

Causes of dyspepsia H.pylori +

79 (6.75%)

27 (2.30%)

1,062 (90.69%)

3 (0.31%)

68 (86.07%)

17 (62.96%)

528 (49.72%)

2 (66.66%)

Kachintorn U, et al.1999

N = 1,171 Overall H.pylori + ve 52.52%

Pharmacological intervention for

• Subtype of Dyspepsia (Ulcer – like or dysmotility –

like or reflux-like dyspepsia)

• PPI were significant more effective than H2RA and

antacid

40% improved with H2RA or antacid

60% improved with PPI

The Cochrane Database of Systemic – Review 2005

This patient

• Empirical treatment

• PPI for 2 – 4 weeks

• Advise : Natural history of disease

: Life – style modification

• Follow up

Case 1

The patient was advised to modified the life style.

He was on omeprazole (20mg) 1x1

domperidone (10 mg)1x3

Simethicone 1x3

At 2 week follow up his symptoms were improved and

he was advised to continue the same treatment for 6

weeks.

Case 1

• ค์'าแนะน'าในกิารปฏิ�บ�ต�ต�ว งดัเหัล�า บ�หัร !

กิ�นอาหัารตรงเวลางดัอาหัารรสิจั�ดัหัล กิเล !ยงยาท !กิระต��นใหั�เกิ�ดั

อากิาร• กิารต�ดัตาม้กิารร�กิษา

Case 1 episode 2

•หัล�งจัากิหัย�ดัยา - 2 3 เดั�อน ม้ อากิารปวดัแสิบท�อง ถิ�ายดั'าเล9กิน�อย ไม้�กิ�นยาบ'าร�ง ซื้�(อยา omeprazole กิ�นเองตาม้ร�านขายยา 1 wk อากิารแสิบท�องไม้�ดั ข3(นจั3งม้าตรวจัซื้'(า

Case 1 episode2

• Thai man, mild pale, no jaundice

• No lymphadenopathy

• Lung & Heart normal

• Abdominal soft, not tender, liver &

spleen can’ t be palpable

• PR melena, no mass

• No signs of chronic liver disease

Recurrence dyspepsia

PU CA Gastritis

Endoscope

Biopsy• HP. Test

HP.• Pathology malignancy

Inflammatory cell

ถิ�ายดั'า Anemia

ถิ�าอาจัารย�ค์�ดัถิ3ง H.pylori

infection จัะใหั�กิารร�กิษาเลยโดัยท !ไม้�ต�องสิ�องกิล�องไดั�หัร�อไม้� หัล�งจัากิเจัาะเล�อดัพบ positive

serology test

A survey of etiology of dyspepsia and prevalence of H.pylori infection in every regions of Thailand

Causes of dyspepsia H.pylori +

79 (6.75%)

27 (2.30%)

1,062 (90.69%)

3 (0.31%)

68 (86.07%)

17 (62.96%)

528 (49.72%)

2 (66.66%)

Kachintorn U, et al.1999

N = 1,171 Overall H.pylori + ve 52.52%

Laboratory findingsLaboratory findings

• CBC:Hct 33%, Wbc 9000 PMN 65% L 30%

Mono 3% Eos 2%

• Stool examination : no parasite ,no wbc no rbc

stool occult blood positive

ถิ�าผู้ลกิารตรวจั Rapid urease test ใหั�ผู้ล negative จัะ rule out H.pylori ไดั�หัร�อไม้� และอาจัารย�จัะร�กิษาอย�างไร

กิารว�น�จัฉั�ย H. pylori Diagnostic test

Sensitivity Specificity

Histology - 93

99 - 95 99% Urea breath test

- 13CO2

98% - 80 99% - 14CO

2 - 90

98% - 92 100%Serology 88

- 96% - 89

99% - 86Rapid urease test - 86Rapid urease test

97%97% - 86 98% - 86 98%Culture -77

94% 100%

False negative for rapid urease test

• High dose H2RA

• PPI

• Antibiotic

• Active UGI bleeding

• Pathologic findings: mild gastritis with

presence of H pylori.

First line therapy (7-14 days)

PPI or Amoxycillin 1 gm bid*

RBC + Clarithromycin + or

bid 500 mg bid Metronidazole 500 mg bid

or PPI/RBC + Amoxycillin + Metronidazole

Second line therapy (7-14 days)

PPI bid + Bismuth subsalicylate/subcitrate 120 mg qid +

Metronidazole 500 mg tid + Tetracycline 500 mg qid

HP. Eradication

Case 2Case 2

•หัญิ�งไทย โสิดั 28 ป0 อาช พ ร�บราชกิารค์ร-•จั�กิแน�นท�อง ร�วม้กิ�บถิ�ายอ�จัจัาระบ�อย 2 เดั�อน•จั�กิแน�นท�องบร�เวณล�(นป0! เล9กิน�อย ร�วม้กิ�บอากิาร

ถิ�ายอ�จัจัาระบ�อย ว�นละ - 34 ค์ร�(ง หัล�งร�บประทานอาหัาร บางค์ร�(งม้ ม้-กิปน แต�ไม้�พบเล�อดั น'(าหัน�กิไม้�ลดัหัร�อเบ�!ออาหัาร

• ไปพบแพทย� 4 ท�าน บอกิเป<นโรค์กิระเพาะ โรค์ประสิาทลงกิระเพาะ ไดั�ยากิ�นไม้�ดั ข3(น กิ�งวลว�าจัะเป<นม้ะเร9ง

• ไม้�ดั�!ม้สิ�รา กิ�นอาหัารตรงเวลา

Case 2Case 2

• A Thai woman not pale, no jaundice, No signs of hyperthyroidism, no signs of malnutrition (edema, vitamin deficiency)

• BP 120/80 torr, Pulse 75/min, BT 36.7 ๐C

• Lung & heart WNL

• Abdomen: soft ,no distension,

liver & spleen can’t be palpable

• No sign chronic liver disease

• PR normal

สิาเหัต�ท !น�าค์�ดัถิ3งในผู้-�ป.วยรายน (A) IBSB) IBDC) ParasiticD) CA colon

Case 2Case 2

A young lady with :

• Abdominal discomfort (epigastrium),

• Chronic diarrhea ( no bloody stool).

• Normal physical examination.

Chronic diarrhea

Functional Organic

Some ‘red-flag’ symptoms and signs suggesting organic gut disease

• Rectal bleeding

• Weight loss*

• Continuous diarrhea

• Constant and recent distension

• Anemia

• Fever

* Occasionally IBS patients lose weight because they food

intake to avoid meal-induced symptoms

IBSIBS

Diarrhea ConstipationAbdominal

discomfort

Distribution of abdominal pain induced by balloon inflation

Prevalence of IBS among Thai, American and British

Thai American British

Rural Urban

No of subjects 401 676 789 301

Mean age 41 31 24 NA

% women 56 31 58 55

Change bowel pattern due to 3.5 21.3 70.5 NA

stress(%)

Abdominal pain due to stress 1.8 15.5 54.1 NA

Painless diarrhea 0 3.6 4.9 4.7

Painless constipation 9.5 7.1 17.5 10.3

Spastic colon syndrome 5.7 4.3 22.3 13.6

DiagnosesDiagnoses

Most likely diagnosis is IBSIBS

Differentiate diagnoses :• Giardiasis

• Strogyloidiasis

• Lactose intolerance

• IBD

• Drugs

Some drugs commonly disturb bowel function

Drugs causing constipation

• Opiates (e.g. codeine, morphine)

• Phenothiazines (e.g. chlorpromazine)

• Tricyclic antidepressants (e.g. amitriptyline)

• 5-HT3 antagonist (e.g.

ondansetron)

• Calcium channel blockers

• Anticholinergics

• Calcium carbonate

Drugs causing diarrhea

• Misoprostol

• Cisapride

• Antacids containing magnesium hydroxide

• Herbal teas containing senna

• Alcohol

• Caffeine

Symptom criteria to exclude organic disease in patients with possible IBS

Young age group

Chronic recurrent symptoms

Mild to moderate symptoms

No signs of organic disease

Middle age

New onset of symptoms

No signs of organic

disease

Age > 50 yr

Change in

symptoms or new

onset of symptoms

Severe symptoms

Sign of organic

disease

Minimal diagnostic

work up

Limited diagnostic

work up

Full diagnostic

work up

Initial work-up in patients with suspected IBSInitial work-up in patients with suspected IBS

• History• Physical examination

(including digital examination of rectum)• CBC• Erythrocyte sedimentation rate• Occult faecal blood test • Colonic examination (discussed on an

individual basis)• Abdominal ultrasound (discussed on an

individual basis)

• CBC : Hct 40%, Wbc 8500, PMN 82%

L18%, Mono 1%, Plt 180000

• Stool exam : no parasite, no rbc

no wbc, occult blood –ve

Sigmoidoscopy : normal

Randomized , Double-Blind, Placebo-Controlled Treatment Trial for the Irritable Bowel Syndrome

Reference a

Antispasmodic agents

Bertherlot,1981, France

General Practitioner Research Group, 1976, U.K.

Kruis ,1986, Germany

Page,1981, U.S.A.

Test agent

Mebeverine

Dicyclomine

Mebeverine

Dicyclomine

Patients entered

Length oftreatment

period(wk)

Rx groups’baseline

characteristic compared?

Activetreatment response

Placeboresponse

Kenneth D Klein. Gastroenterology. 1988.

Randomized , Double-Blind, Placebo-Controlled Treatment Trial for the Irritable Bowel Syndrome

Test agent

Ispaghula

Psyllium

Ispaghula

Loperamide

Reference a

Bulking agents

Arthurs, 1983, Ireland

Longstreth, 1981, U.S.A.

Prior, 1987, U.K.

Opioids

Hovdenak, 1987, Norway

Patients entered

Length oftreatment

period(wk)

Rx groups’baseline

characteristic compared?

Activetreatment response

Placeboresponse

Kenneth D Klein. Gastroenterology. 1988.

Newly approved prescription treatment for IBS

• Treatment•Tegaserod maleate1

• 5 – HT4 receptor partial agonist

• Indicated for the short – term treatment of women with IBS whose primary bowel symptom is constipation

• Alosetron hydrochloride2

• 5 – HT3 receptor partial agonist

• Indicated only for women with severe diarrhea – predominant IBS who have

• Chronic IBS symptoms (generally lasting 6 months or longer)• Has anatomic or biochemical abnormalities of the GI tract excluded • Failed to respond to conventional therapy

ท�านจัะเล�อกิใช�ยาอะไรA) Imodium

B) Buscopan

C) Mebeverine

D) Psyllium

Recommendations

• Various antispasmodics can be given to

reduce pain, those with an anticholinergic

action appearing to be slightly more effective

• Tricyclic antidepressants can be beneficial for

pain, initially at a low dose, but occasionally

higher doses may be required. They are best

avoided if constipation is a major feature

Recommendations

• Patients with urgency and diarrhea can be

successfully treated with loperamide at doses of

4 - 12 mg daily. Codeine is a reasonable alternative

but more likely to cause unwanted sedation

• A small number of patients with diarrhea

predominant IBS have bile salt malabsorption and

may response to cholestyramine

Case 2 Treatment

• ใหั� Mebeverine 1x3 , Imodium 1 tab prn, Buscopan 1 tab prn

น�ดัม้าดั ข3(น ใหั�ร�กิษาใกิล�บ�าน • 6 เดั�อน ต�อม้าม้ อากิารปวดัท�องม้ากิข3(นใหัม้� นอน

ไม้�หัล�บ กิ�งวลม้ากิ ว�าจัะเป<นม้ะเร9งอ กิ โดัยม้ ล-กิของค์�ณอาเป<นม้ะเร9งล'าไสิ�ใหัญิ� ตอนอาย� 40 ป0 เม้�!อ 1 เดั�อนกิ�อน จั3งม้าตรวจัซื้'(า

• ไม้�ม้ น'(าหัน�กิลดั ไม้�ม้ ไข� ย�งกิ�นไดั�ดั ไม้�อาเจั ยน

Case 2 episode 2

•CBC normal•Stool exam normal•ค์'าแนะน'าและกิารร�กิษา

เพ�!ม้เต�ม้

Patients in English general practice with fear of cancer or other serious disease

Percentage of Percentage of patients

patients with IBS* with organic disease

(n = 76) (n = 100)

Fear of cancer 46 30 (p < 0.04)

Fear of other disease 9 10

Total with fear 55 40(p < 0.05)

FOBT vs SIGMOIDOSCOPY (FS) vs COLONOSCOPY in detection of FOBT vs SIGMOIDOSCOPY (FS) vs COLONOSCOPY in detection of colorectal cancercolorectal cancer among Chinese among Chinese

505 asymptomatic adults older than 50 years were recruited from the general public through health exhibitions. All enrolled subjects were offered FOBT and full colonoscopy under sedation.

476 (94.3%) had a complete colonoscopy were recorded. Lesions at the distal 40 cm in the left colon and rectum were taken as findings of FS.

Advanced colonic lesions* sensitivity specificity

FOBT 14.3% 79.2% FS 77.8% 83.9% Combining FOBT with FS would not significantly improve the results of FS alone.

Among the 385 subjects with a normal distal colon, 14 (3.6%) had advanced lesions in the proximal colon that would be missed by FS alone.

* Advanced colonic lesions = adenoma > or = 10 mm, villous adenoma, adenoma with moderate or severe dysplasia, or invasive cancer

Sung JJ et al Gastroenterology. 2003 Mar;124(3):608-14

Management guideline for IBS

• Listen to the patient • Explanation and reassurance • Healthy lifestyle advice • Dietary advice • Psychological considerations • Psychological treatment• Pharmacological approach

Do’s and don’ts of IBS management

Do’s• Approach the patient

empathically• Explore any hidden

agenda• Explain nature of the

disorder thoroughly

Don’ts • Discourage the patient

from seeing you again• Punish the patient• Assume psychogenic

origin of the symptoms without proper assessment

• Feel forced into repeated or needless investigations

This presentation is placed on the

website of Department of Medicine,

http://www.med.mykku.net

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